Provider Demographics
NPI:1346458411
Name:KAKKANATHU, JOHN JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:KAKKANATHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 3016B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6339
Mailing Address - Fax:314-251-4564
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 3016B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6339
Practice Address - Fax:314-251-4564
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009008964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1346458411Medicaid
MOP00744531OtherRAILROAD MEDICARE
MO133360013Medicare PIN
MO1346458411Medicaid